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MUSICAL DYNAMICS

IN TIME-LIMITED INTERSUBJECTIVE

CHILD PSYCHOTHERAPY

AN EXPLORATION BASED ON MICROANALYSIS OF THERAPEUTIC INTERPLAY

BY

UNNI TANUM JOHNS

DISSERTATION SUBMITTED 2018

MUSICAL DYNAMICS IN TIME-LIMITED INTERSUBJECTIVE CHILD PSYCHOTHERAPY

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Thesis submitted: xxxxxxxxx

PhD supervisor: Prof. Lars Ole Bonde,

Aalborg University

Assistant PhD supervisor: Associate Prof. Bjørg Røed Hansen,

University of Oslo

PhD committee: Prof. Ulla Holck

Aalborg University

Prof. Leslie Bunt

Prof. Katharina Mårtenson Blom

PhD Series: Faculty of Humanities, Aalborg University

ISSN: xxxx- xxxx

ISBN: xxx-xx-xxxx-xxx-x

Published by:

Aalborg University Press

Skjernvej 4A, 2nd floor

DK – 9220 Aalborg Ø

Phone: +45 99407140

[email protected]

forlag.aau.dk

© Copyright by author

Printed in Denmark by Rosendahls, 2018

mailto:[email protected]


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CV

Unni Tanum Johns is a music therapist (Guildhall School of Music with Juliette Alvin

and advanced clinical studies with Paul Nordoff and Clive Robbins), an authorized

psychologist (University of Oslo) and specialist in clinical child- and adolescent

psychology (NPF). She currently has a clinical position at Akershus University

Hospital HF, Furuset child and adolescent outpatient Clinic. She is Associate

Professor at The Department of Psychology, University of Oslo. She participated in

establishing the Music Therapy education program in Norway, and in developing an

interdisciplinary Specialist Program in Intersubjective Child and Adolescent

Psychotherapy at the Regional Centre for Child and Adolescent Mental Health,

Eastern and Southern Norway (RBUP) (Svendsen et al., 2012; Johns, 2012b). She has

additional studies in the treatment of trauma in children and adolescents (Johns, 2017),

and has been teaching and supervising music therapy and psychology to students and

professionals for many years. Her clinical and academic focus of interest is the

integration of empirical knowledge with creative approaches to development and

change processes in psychotherapy with children, adolescents and their families,

taking as a starting point their individual experiences, needs and contexts. During

many years of clinical practice, the significance of non-verbal intersubjective

meetings came to the forefront (Johns, 1993, 1996, 2012a). From 2002, she

participated in initiating and implementing a research project on time-limited child

psychotherapy with children experiencing difficult family situations (Haugvik &

Johns, 2006, 2008; Johns, 2008; Haugvik, 2013). This led to further development and

writing on the subject (Svendsen & Johns, 2013; Johns). The present research builds

on the previous research study, and findings from this study comprise the background

knowledge for further analysis and research proceedings in the present study.

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PUBLICATIONS LEADING TO THE PRESENT STUDY

Haugvik, M. & Johns, U. (2006). Betydningen av felles fokus i tidsavgrenset

psykoterapi med barn: En kvalitativ studie av psykoterapi med barn som opplever

vanskelige familieforhold. [The significance of a shared focus in time-limited

psychotherapy with children experiencing difficult family situations]. Tidsskrift

for Norsk Psykologforening, 43 (1), 19-29.

Haugvik, M. & Johns, U. (2008). Facets of structure and adaptation: A qualitative

study of time-limited psychotherapy with children experiencing difficult family

situations. Clinical Child Psychology and Psychiatry, 13(2), 235–252.

Haugvik, M. (2013). Structured parallel therapy with parents in time-limited

psychotherapy with children experiencing difficult family situations. Clinical

Child Psychology and Psychiatry,18, 504-518.

Haugvik, M. & Mossige, S. (2017). Intersubjectively oriented, time-limited

psychotherapy with children: how does the therapist evaluate the therapeutic

process and what are the therapist’s tasks? Journal of Child Psychotherapy, 43

(3), 353-368.

Johns, U. (1993). Intersubjektivitet som grunnlag for utvikling [Intersubjectivity as a

foundation for development]. I G. Trondalen & E. Ruud (Eds.). Perpsektiver på

Musikk og Helse. 30 år med Norsk Musikkterapi (pp. 67-84). Oslo: NMH-

publikasjoner 2008:3. Skriftserie fra Senter for Musikk og Helse (vol. 1).

Johns, U. (1996). Stemmen som formidler av følelser og kommunikasjon: Et

utviklingspsykologisk og et psykodynamisk perspektiv. [The voice as conveyer of

emotions and communication: A perspective from developmental and

psychodynamic psychology]. (Master thesis, Cand. Psychol., University of Oslo].

Johns, U. T. (2008). ‘Å bruke tiden – hva betyr egentlig det?’ Tid og relasjon i et

intersubjektivt perspektiv. [‘To spend the time – what does it really mean’? Time

and relations in an intersubjective perspective] In G. Trondalen & E. Ruud (Eds.).

Perspektiver på musikk og helse. 30 år med norsk musikkterapi (pp. 67-84). Oslo:

NMH-publikasjoner 2008:3. Skriftserie fra Senter for Musikk og Helse (vol. 1).

Johns, U. T. (2012). Vitalitetsformer i musikk. I G. Trondalen & K. Stensæth (Eds.),

Barn, musikk, helse (pp. 29-44). Oslo: NMH publikasjoner 2012:3. Skriftserie fra

Senter for musikk og helse, (vol.3).

Johns, U. T. (2012). Terapeututvikling: Musikken i det terapeutiske samspillet.

[Therapeutic development: The music in the therapeutic interaction]. I Svendsen,

B., Johns, U., Brautaset, H. & Egebjerg, I. (2012), Utviklingsrettet intersubjektiv

psykoterapi med barn og unge. Bergen: Fagbokforlaget.

Svendsen, B., Johns, U., Brautaset, H. & Egebjerg, I (2012). Utviklingsrettet

intersubjektiv psykoterapi med barn og unge. [Developmentally directed

psychotherapy with children and adolescents]. Bergen: Fagbokforlaget.


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ENGLISH SUMMARY

The aim of this PhD study is to explore the influence of non-symbolic microprocesses

in time-limited intersubjective child psychotherapy through a musical frame. It builds

on microanalytic research, from infant development and music therapy, demonstrating

how musical elements can describe and illuminate variations in emotional expressions

and relationship qualities. There are until now few studies applying a microanalytic

‘musical’ approach to investigate therapeutic interplay with children referred to

mental health services.

Problems with emotion regulation are found in a wide range of diagnoses, affecting

the quality of children´s lives. Therefore, the facilitation of emotion regulation is a

central goal for child psychotherapy. Knowledge from developmental research shows

how affective, non-symbolic reciprocal moment-to-moment interplay underlie and

organize self-developmental processes.

Based on previous research findings and knowledge from infant research with

reference to musical parameters, such as vocalizations, timbre, pitch, melodic contour,

intensity, rhythm and tempo, as concrete descriptions of intersubjective exchanges,

this PhD study aimed at investigating the following three main research questions

through a phenomenological hermeneutic approach:

1. Can musical parameters be useful to capture intersubjective exchanges

between therapist and child – and if so, how?

2. Can a description of musical parameters, within a multilayered frame,

illuminate intersubjective microprocesses – and if so, how?

3. Can a phenomenological description and a hermeneutic interpretation

of musical parameters, clarify therapeutic interplay and basic

developmental processes such as emotion regulation in child

psychotherapy – and if so, how?

Two emotion regulation samples of therapeutic interplay with six children, from an

early and a late therapy session, are analysed. Applying a qualitative explorative

approach, a multi-layered research procedure was firstly developed, including a

musical framework as well as a psychological (Johns, 2018). The musical frame is a

registration of vocal, rhythmical, dynamic and temporal changes as concrete

descriptions of the specificity of therapeutic exchanges, as these unfold. The concept

of musical dynamics is suggested as a description of lived relationship experiences

over time.


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Data were drawn from a mixed-method multicentre study, taking place at the

Norwegian University of Science and Technology in Trondheim and at a child- and

youth psychiatric outpatient clinic at Akershus University Hospital in Oslo. Research

target was changes in emotion regulation in children 9-13 (36) with diagnoses within

the internalizing spectrum. Controls (28) were recruited from local schools in

Trondheim. Participants were assessed before and after therapy with multiple

methods, including psychophysiological measures, which are not a topic for this PhD.

Assessment with the Affect Consciousness Interview (ACI) were administered before

and after therapy, to obtain objective measures of affect integration. These measures

were applied as validation of findings and are described in article 2 in the PhD.

The qualitative multi-layered microanalysis revealed some patterns across samples

which demonstrate how a musical dynamics-based description embody and clarify the

child´s activity, emotional expressions and intentions as well as illuminate

intersubjective exchanges.

Findings from the Affect Conscious Interview (ACI) for each of the six children in

the study, compared to the non-clinical control group, indicate increased affect

integration and development of emotion regulation capability towards an age adequate

status. These findings support an understanding of time-limited child psychotherapy

as a frame for developmentally directed intersubjective microprocesses.

This PhD study contributes to clinical research and practice within child

psychotherapy by showing how a musical dynamics-based description, as part of a

multi-layered microanalysis, can clarify the specificity of both the child´s and

therapist´s activity, enabling intersubjective sharing and self-development. A focus on

the musical dynamics of therapeutic activity can further contribute to therapeutic

development by sensitizing therapists to qualities in their own activity, which promote

responsivity to the child.

The thesis consists of two articles. The first describes the development of the

microanalytic research procedure, and the other paper presents and discusses findings.

A short summary of articles is given in sections 1.6.1 and 1.6.2. As part of the

multicanter study, a handbook was written on the treatment method, integrating

research findings and is included together with a linking text. A summary of the

handbook is written as part of the description of the therapy method in section 1.2.3.

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LIST OF PHD PUBLICATIONS

Article 1

Johns, U.T. (2018). Exploring musical dynamics in therapeutic interplay with

children: A multilayered method of microanalysis. Nordic Journal of Music Therapy,

27 (3), 197-217.

Article 2

Johns, U.T. (submitted 2018). A study of musical dynamics in therapeutic interplay

with children: ’The important thing was to be understood through tone of voice and

movements’.

Treatment manual

Johns, U.T. & Svendsen, B. (2016). Håndbok i Tidsavgrenset Intersubjektiv

Barneterapi (TIB). Kunnskapsgrunnlag, behandlingsprinsipper og eksempler.

[Handbook in Time-Limited Intersubjective Child Psychotherapy (TIC): Knowledge

base, Treatment Principles and Examples]. Bergen: Fagbokforlaget.

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NORSK SAMMENFATNING

Denne PhD studien har som mål å utforske non-verbale mikroprosesser i tidsavgrenset

intersubjektiv barneterapi gjennom en musikalsk tilnærming. Den bygger på

mikrostudier fra spedbarnsforskning og musikkterapi, som viser hvordan musikalske

elementer kan beskrive og belyse kvalitative variasjoner i emosjonelle uttrykk og i

relasjoner. Det er til nå få studier som anvender en mikroanalytisk ’musikalsk’

tilnærming for å undersøke terapeutisk samspill med barn som er henvist til psykisk

helsetjenester.

Problemer med emosjonsregulering er relatert til en rekke forskjellige diagnoser, og

innvirker på kvaliteten i barns liv. Derfor er utvikling av emosjonsregulering et

hovedmål for barneterapi. Kunnskap fra spedbarnsforskning viser hvordan mønstre i

affektive, ikke-symbolske og gjensidige mikroprosesser organiserer selv-

utviklingsprosesser.

Basert på funn fra en tidligere forskningsstudie sammen med kunnskap fra

spedbarnsforskning som refererer til musikalske parametre, som vokaliseringer,

klangfarge, tonehøyde, melodisk kontur, intensitet, rytme og tempo som konkrete

beskrivelser av intersubjektive utvekslinger, har denne PhD studien hatt som mål å

utforske tre hovedforskningspørsmål gjennom en fenomenologisk-hermeneutisk

tilnærming:

1. Kan musikalske parametre være nyttige i å fange opp intersubjektive

utvekslinger mellom terapeut og barn – og i så fall, hvordan?

2. Kan en beskrivelse av musikalske parametre, som del av en flerlags ramme,

belyse intersubjektive mikroprosesser – og i så fall, hvordan?

3. Kan en fenomenologisk beskrivelse og en hermeneutisk tolkning av

musikalske parametre, klargjøre terapeutisk samspill og grunnleggende

utviklingsfenomener som emosjonsregulering i barneterapi – og i så fall,

hvordan?

To samples på emosjonsregulerings samspill, fra en tidlig og en sen terapitime med

seks barn 9-11 ble analysert. På basis av en kvalitativ eksplorerende tilnærming, ble

det først utviklet en flerlags mikroanalyse metode bestående av en musikalsk og en

psykologisk ramme (Johns, 2018). Den musikalske rammen er en registrering av

vokale, rytmiske, dynamiske og temporale endringer, som konkrete beskrivelser av

spesifikk aktivitet hos barnet eller terapeuten fra øyeblikk til øyeblikk. Begrepet

‘musikalsk dynamikk’ (‘musical dynamics’) er foreslått som en beskrivelse av levde

relasjonelle opplevelser over tid.


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Data kommer fra et multisenter prosjekt, ved Norges Teknisk Vitenskapelige

Universitet (NTNU) i Trondheim i samarbeid med BUP Furuset, Akershus

Universitetssykehus HF. Forskningsformålet er å studere endringer i

emosjonsregulering hos barn 9-13 med internaliserende vansker. Kontrollgruppe er

rekruttert fra lokale skoler I Trondheim. Deltagere ble målt før og etter terapi med

multiple metoder, inkludert psykofysiologiske mål, som ikke er tema for PhD studien.

Affektbevissthetsintervju ble foretatt før og etter terapi, for å få objektive mål på

affektintegrasjon. Disse målene ble brukt som validering av kvalitative funn, og er

beskrevet i artikkel 2 i studien.

Gjennom de kvalitative mikroanalysene fremkom det noen mønstre på tvers av

eksempler som viser hvordan en musikalsk dynamisk beskrivelse av det terapeutiske

samspillet med barnet inkorporerer barnets aktivitet og belyser barnets emosjonelle

uttrykk og intensjoner, så vel som å belyse intersubjektive utvekslinger.

Funn fra affektbevissthetsintervjuene for hvert barn, sammenlignet med

kontrollgruppen, indikerte økt affektintegrasjon og utvikling av emosjonsregulering i

retning av aldersadekvat status. Funnene støtter forståelsen av intersubjektive

tidsavgrenset barneterapi som en ramme for utviklingsrettede mikroprosesser.

PhD studien bidrar til klinisk forskning og praksis gjennom å vise hvordan en

beskrivelse av den musikalske dynamikk i det terapeutiske samspillet kan bidra til å

klargjøre spesifikke bevegelser hos barnet eller terapeuten som bidrar til

intersubjektiv deling og selvutvikling. Fokus på musikalske elementer og kvaliteter i

terapeutisk aktivitet kan bidra til terapeutisk utvikling gjennom økt sensitivitet og

oppmerksomhet på kvaliteter som fremmer responsivitet overfor barnet.

PhD studien består av to artikler, den første omhandler utvikling av en flerlags

mikroanalysemetode og den andre presenterer og diskuterer funn som fremkommer

gjennom analysene. En håndbok som beskriver behandlingsmetoden og som

integrerer funn fra studien er også inkludert sammen med kappen.

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ACKNOWLEDGEMENTS

This project has been a long journey full of winding new roads of challenges, learning

and surprises and I am immensely glad and grateful to have reached the end. Many

are those who have inspired, supported and contributed along the way.

Firstly, I want to thank the children and parents who have taken part in the study, and

without whose participation, sincerity and valuable comments I would have been

much poorer in both knowledge and outcome.

The study could not have been fulfilled without the support and enthusiasm of two

leaders at the Furuset child- and adolescent outpatient clinic during the research

period, Gro Traavik and Marianne Kveldstad. Their confidence in the significance of

qualitative clinical research and the courage to participate in a multicentre study has

been priceless. Also, I want to thank my colleagues, who have participated as

therapists and collaborators in the mixed method study. Marianne Haugvik, with

whom the first study of time-limited child psychotherapy was initiated, has been very

important in the work to broaden the scope of opportunities for clinical research.

A very special thank goes to my supervisor Lars Ole Bonde! Your creative and

knowledgeable mind, wise questions and often surprising ideas, your combination of

endless patience and impatience with everything that got in the way – all of this has

made the project and me develop – and I am deeply grateful!

I will be forever grateful to my wise supervisor on child psychotherapy research

Bjørg Røed Hansen. She has been my teacher and supervisor since 1991, when she

was the co-founder of the first child psychotherapy seminar at the University of Oslo.

She brought Daniel Stern to Oslo, and intersubjectivity to psychotherapy. Without

her pioneering work, this study might not have had the solid developmental and

psychological theoretical fundament to make meaning out of therapeutic

microprocesses.

Another key person to this study is Birgit Svendsen, who took the initiative to a mixed

method multicenter study of child psychotherapy, the first in Norway to apply

psychophysiological measurements in addition to qualitative method. Birgit’s

methodological skills, courage, global enthusiasm and talent in involving

collaborators has been crucial.


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The first person who eagerly supported an integration of music and psychology to

study nonverbal communication in child psychotherapy was Tony Wigram,

psychologist, musician, music therapist and researcher at the doctoral school at

Aalborg university. He made me believe that it was possible, worthwhile and fun to

research! Years later when I finally decided to pursue the project, I have had the

privilege of being a part of the international Aalborg research family. I am grateful

to Hanne Mette Ridder for always being attentive to practical, social and professional

issues, and to the other teachers on the program for the many unformal gatherings

and valuable exchanges. Presenting my ideas to a group with teachers and students

of such diversity in cultural and professional backgrounds has been enriching.

Invaluable backing from the beginning came from my friend and colleague Gro

Trondalen, whose continued support in everything from technical data challenges to

discussions about research issues has been of vital importance for which I am

grateful.

Thank you to my children Jonas, Ingrid and Niklas, who has always broadened my

perspectives and brought pleasurable distraction, and to my husband Erling who has

been there the whole time with patient and endless support and care.

Bjørg and Birgit both passed away much too early, Birgit in 2016 and Bjørg in 2018.

Their enthusiasm for child psychotherapy never ceased to exist and they followed the

research project to the end of their lives with the same passion and persistence. I

dedicate this work to them.

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TABLE OF CONTENTS

LIST OF PHD PUBLICATIONS .......................................................................... 11

Chapter 1. Introduction .......................................................................................... 21

1.1. Context of study ............................................................................................ 22

1.2. Personal motivation ....................................................................................... 23

1.3. Purpose of the study ...................................................................................... 24

1.4. CONCEPTUAL FRAMEWORK AND TERMINOLOGY .......................... 25

1.5. Overall structure of the study ........................................................................ 29

1.5.1. Figure 2. Flowchart of the multicenter research study ........................... 29

1.5.2. Therapy method/time-limited intersubjective child psychotherapy ....... 31

1.5.3. Summary of handbook of time-limited intersubjective child therapy (TIC)

......................................................................................................................... 32

1.6. Short summary of the articles of this PhD .................................................... 36

1.6.1. Article 1 (published) .............................................................................. 36

1.6.2. Article 2 (submitted) .............................................................................. 38

Chapter 2. Literature review and theoretical background.................................. 40

2.1. an overview of emPirical studies in child psychotherapy ............................. 40

2.2. A perspective on child psychotherapy as a process of development and

integration ............................................................................................................ 44

2.2.1. Affective dialogue; a matrix for self-development................................. 46

2.2.2. Development of emotion regulation ....................................................... 47

2.2.3. Affect integration ................................................................................... 49

2.3. A musical frame for understanding therapeutic interplay with children ....... 49

2.3.1. An infant research perspective on reciprocal ‘musical’ interplay .......... 51

2.3.2. Perspectives from music therapy ............................................................ 54

2.3.3. Integrating perspectives from musicology ............................................. 57

Chapter 3. Method .................................................................................................. 60

3.1. epistemological and ontological perspectives ............................................... 60

3.2. Research questions ........................................................................................ 62

3.3. Research methododology .............................................................................. 62


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3.3.1. A naturalistic setting .............................................................................. 62

3.4. The database – part of a multicentre study .................................................... 63

3.5. Recruitment and collection ........................................................................... 63

3.5.1. Mixed method study ............................................................................... 64

3.5.2. Affect consciousness interview .............................................................. 64

3.6. The participants ............................................................................................. 65

3.6.1. The children ........................................................................................... 65

3.6.2. The therapists ......................................................................................... 65

3.7. Data analysis - a qualitative methodology .................................................... 65

3.7.1. A phenomenological - hermeneutical approach ..................................... 66

3.8. Microanalysis ................................................................................................ 67

3.8.1. Video method ......................................................................................... 68

3.8.2. Sampling procedures .............................................................................. 68

3.8.3. Developing a multilayered method for video microanalysis .................. 69

3.8.4. Ethical considerations ............................................................................ 70

Chapter 4. Findings................................................................................................. 71

4.1. Summary of findings ..................................................................................... 71

4.2. Summary of affect consciousness interviews ................................................ 73

Chapter 5. Discussion ............................................................................................. 74

5.1. Evaluation of findings in a theoretical perspective ....................................... 75

5.2. Discussion of methodological issues ............................................................. 81

5.2.1. Reflexivity: preconceptions and how the researcher affected the study . 82

5.2.2. Study limitations .................................................................................... 83

5.3. Implications and recommendations ............................................................... 84

5.3.1. Implication and recommendations for clinicians ................................... 84

5.3.2. Implication and recommendations for health politics ............................ 85

5.3.3. Implication for research and future perspectives .................................... 85

5.3.4. Conclusions ............................................................................................ 86

Literature list ........................................................................................................... 88

Articles ................................................................................................................... 101


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TABLE OF FIGURES

Figure 1. Graphic overview of microanalytic research study

Figure 2. Flowchart of multicenter mixed method research study

CHAPTER 1. INTRODUCTION

This study initiated in a previous research project on time-limited intersubjective

psychotherapy with children in difficult family situations (Haugvik & Johns, 2008).

After therapy ended, parents described the children as being clearer about their needs

and with increased ability to share both positive and negative feelings, as well as

symptom reduction. I wanted to study the method further, to search for hallmarks and

enabling conditions of therapeutic interplay facilitating self-regulation and affect

integration. The present study explores the non-verbal therapeutic dialogue in child

psychotherapy through a ‘musical frame’ as part of a microanalytic approach

(Tronick, 1998, 2007; Trevarthen, 2001; Stern, 2004; Harrison, 2013).

The primary aim is to illuminate and clarify features of dialogical exchanges, which

promote self-development in the child. The study is an integration of knowledge from

several areas:

Firstly, empirical infant research has opened doors into the possibilities of

microanalysis of moment-to-moment interplay and in this way has contributed with

knowledge about the intersubjective foundation of human development (Stern, 2000;

Trevarthen, 1980). Specifically, the study draws on the thinking of Daniel Stern and

his contributions on the relevance of infant research to clinical work and on the work

of Colwyn Trevarthen, whose microstudies has greatly contributed to acknowledge

the significance of musical vocal and rhythmical features for relationship qualities.

Secondly, knowledge from music about central and specific features of different

musical parameters and from music therapy, about the role of musical improvisation

in therapeutic work with different client groups, mainly adults.

Thirdly, a study of child psychotherapy needs to include child-specific knowledge

(Hansen, 2012; Johns, 2012). This includes child-specific emotional, cognitive and

somatic reactions. Children are different from adults, and such knowledge from

developmental psychology is necessary to communicate meaningfully and help

children and parents to make sense of their experiential world. Empirical infant

research has so far played a small part in child psychotherapy research and practice.

Children´s experiential world come to the forth, firstly through somatic, emotional

nonverbal expression. Therefore, psychotherapy should address such signals both

clinically and as a focus for research.


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1.1. CONTEXT OF STUDY

The research context is a multicenter study in child psychotherapy, which has been

taking place from 2014 at the Norwegian University of Science and Technology in

Trondheim, Norway, and at the Akershus University Hospital’s Child and Adolescent

Mental Health Clinic at Furuset, Oslo. The head of research is Professor Karl

Jacobsen, NTNU.

The project initiated in research on emotion regulation, influencing the understanding

of emotion regulation as a basic phenomenon across a variety of children´s diagnoses.

This has inspired an increased focus on the regulation, organization and integration of

affects in clinical work and research, which is also the background for the multicentre

study. The study applies several measures, both quantitative, such as

psychophysiological measures and qualitative, where this PhD represents a qualitative

video microstudy of emotion regulation interplay. On the background of comparative

findings from previous studies on psychophysiological measures, it was decided to

include children presenting with symptoms in the internalizing spectrum (anxiety,

depression or somatization).

The treatment context is Time-limited Intersubjective Child psychotherapy (TIC),

which has been developed in Norway for the past decades as a frame, for

intersubjective processes directed at self-development (Hansen, 1991a, 1991b, 2012).

It merges individual work with the child and parent therapeutic work. Theoretically,

it originates in a psychodynamic approach and has integrated knowledge from infant

research and creative arts.

Time-limited intersubjective child psychotherapy has been subjected to research since

the beginning of this century and the second clinical research background is a previous

research project on time-limited intersubjective therapy (Haugvik & Johns, 2008;

Haugvik, 2013; Haugvik & Mossige, 2017; Johns, 2008). Findings here showed that

parents, after therapy ended, described the children as being clearer about their needs

and having increased ability to share both positive and negative feelings. Findings

were supported by symptom reduction on symptom scales.

These findings inspired a further study on the impact of this treatment approach on

children´s emotional development, within the context of a musical frame, as a well-

used context in infant research to describe intersubjective microprocesses.

The clinical context and site of research is a natural clinical setting in an outpatient

mental health clinic for children and adolescents in Oslo and at a university student

clinic in Trondheim. Measurements and treatment procedures were carried out on

these sites. Three of the therapists are experienced specialists in clinical child and

adolescent psychology, the author being one of these also being an experienced music

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therapist. Two of the therapists are advanced clinical psychology students under close

supervision.

1.2. PERSONAL MOTIVATION

My personal motivation for this PhD study comes from clinical experience with

children in psychotherapy, together with a background as music therapist. Clinical

work with children has shown me the potentiality and richness of the therapeutic

dialogue, both implicitly and explicitly, and of the significance of the child’s

contribution to that dialogue. Meeting a child in the here and now and sharing the

child´s story from the child’s perspective, has had developmental value for me as a

child therapist. It has encouraged an interest in further knowledge about phenomena

influencing change processes from a dialogical micro perspective. My training, as a

child psychologist, has been within an intersubjective approach, which supports a

developmental view on child psychotherapy and emphasize the significance of

microprocesses in the therapeutic dialogue. Meeting children who struggle

emotionally, has shown me the therapeutic strength in children´s immediate implicit

and explicit signals to what goes on in the relationship. This has greatly inspired a

broadening of my understanding of the therapeutic relationship.

My background as a music therapist has influenced the way I experience encounters,

whether non-verbal or verbal, from a musical perspective, in which variations in

rhythm, tempo, silences, vocal tonality etc. play an important part in influencing

subjective experiences of an encounter. Children in therapy sometimes spontaneously

comment on what I think of as musical, non-verbal affective qualities in therapeutic

dialogues. In working with children who do not play, either because of traumatic

background or emotional neglect, it always makes an impression on me that when

they develop the capability to play through therapy, singing or humming often

accompany playing, with increased vitality. I have asked myself if it is also an

expression of increased emotional regulation, integration and flexibility, and I have

been motivated to explore these aspects further in child psychotherapy, combining a

musical with a psychological approach to microprocesses in the therapeutic interplay,

inspired by similar studies in infant research.

Beside the above sources of motivation, there are two more issues, which concern me

as a child psychologist: Firstly, the right of children to express their feelings and

needs, independent of grown-ups, as formulated in the United Nations Convention on

the Rights of the Child. For this to happen, they dependent on the support from the


24

adult world. Secondly, since children seldom seek therapeutic help on their own

account, therapy must be understandable and meaningful from the perspective of the

individual child. Since children express themselves mainly in the here and now and

the non-verbal domain has priority above the verbal, psychotherapy with children

must favour a further understanding of non-verbal emotional communication.

1.3. PURPOSE OF THE STUDY

Summarized, two broad fields of knowledge from research inform the background for

the formulation of research questions that have guided the analysis of the present

study:

Firstly, research documenting how emotional disorders have serious impacts on the

lives and development of children and is an important area for research and

knowledge. There are several fundamental differences between children and adults,

implying that knowledge from adult research cannot be transferred directly to children

(Kazdin, 2000). Children communicate their difficulties mainly non-verbally due to

lack of verbal skills, making them more difficult to discover and understand for their

surroundings (ibid.). Kazdin encouraged more studies considering children´s

developmental perspectives. There is a need for studies in naturalistic clinical settings

with actual children who experience emotional disorders (Weisz, 2000). Midgley et

al. (2017) recommend that the research base for child psychotherapy incudes more

studies, in the future, which focus on how a treatment works, in addition to whether it

works. Based on a developmental research perspective (Lyons-Ruth, 2006) and the

role of intersubjectivity, more knowledge about developmental change processes in

in child psychotherapy is an important contribution (Hansen, 2012). A growing body

of knowledge indicates that therapeutic change involves basic developmental

processes, such as attention and emotion regulation (Saarni, Mumme & Campos,

1998; Schore, 2003; Campos, Frankel & Cameras, 2004; Jacobsen & Svendsen, 2010;

Braarud & Nordanger, 2014). The multicenter study, from which the data for this microstudy comes, aims at a broad mixed method study of changes in emotion

regulation.

Secondly, knowledge from infant research, which this microstudy part of the

multicenter research builds on and which shows how such basic self-developmental

processes take place in micro interplay from the start, being influenced by relationship

qualities. Taking a developmental research perspective (Lyons-Ruth, 2006) on child

psychotherapy, the focus is on studying therapeutic interplay between therapist and

child second by second in small emotion regulation samples. From infant research, knowledge about the role of intersubjective microprocesses for human development

has shown how musical parameters help to clarify key aspects of such microprocesses.

25

Infant research has, to a large degree applied fundamental musical parameters, such

as rhythm, timing, vocal tonality and intensity to clarify significant intersubjective

aspects for development.

There is until now, little research on the significance of microprocesses in promoting

developmental change in children with emotional difficulties. There is also less

research on internalizing difficulties in children than in adults. The purpose of this

microstudy is to explore and illuminate therapeutic exchanges between therapist and

child, applying a research procedure, which includes a moment-to-moment

description of musical qualities.

1.4. CONCEPTUAL FRAMEWORK AND TERMINOLOGY

In the following, central theoretical concepts and framework in the thesis are defined.

In addition, terminology is defined in the articles and the thesis to clarify theory.

Intersubjectivity being a central conceptual framework, I will start by describing my

pre-understanding and conceptual theoretical background influencing the study.

Intersubjectivity is a relatively new concept within psychology and psychotherapy

(Hansen, 1991a, 1991b, 2012). It has its roots in philosophy and phenomenology.

Especially Husserl and Merleau-Ponty have contributed to an understanding of the

significance of human sensory and bodily sensations for awareness of subjective

phenomena (Hansen, 2012). I will describe the philosophical influence more in detail

under the method section under a phenomenology. Within psychotherapy, the concept

of ‘object relation’, as part of a psychoanalytic understanding, was challenged by

Jessica Benjamin (1990) who claimed that mutual recognition of subjectivity in the

therapeutic relationship is at the bottom of therapeutic development. Trevarthen´s

research made a major contribution to the understanding of intersubjectivity, leading

to an understanding of intersubjectivity as an inborn human motive for social

engagement. Intersubjectivity thus lie at the bottom of making sense of bodily sensory

experiences of vocal tonality, rhythm and tempo together with the facial expressions

of others, referring to a primary sharing of experiences underlying developmental

processes (Trevarthen & Hubley, 1978; Trevarthen, 1992; Stern, 2003) which take

place in microprocesses from moment to moment. Both emotional and cognitive

development are in this perspective embedded in a shared world of actions and

meaning, something which has led to increased respect for children communication

as something which transcends later cognitive development. It supports a

developmental perspective on psychotherapy, implying that the child´s self-

development is embedded from birth in intersubjective dialogue (Stern, 2000). From

this dialogue, relational patterns and representations of self-with others are

continuously developed, constructed and are subject to reconstruction. This view is


26

embedded in an intersubjective perspective child psychotherapy, together with

therapy as an arena for reconstruction and development. The intersubjective

understanding of child psychotherapy, which is presented here, is that experiences of

subjectivity, mutuality and reciprocal exchanges are decisive for self- and self-with-

others development, also in psychotherapy.

Different theoretical traditions, which also influence my understanding, links

intersubjectivity to forms for interactive regulatory patterns (Beebe, Knoblauch,

Rustin & Sorter, 2005), development of mentalization (Fonagy, Gergely, Jurist &

Target, 2002) and sharing of mental worlds (Stern, 2000, 2003, 2004, 2005). Stern´s

view is that we are part of an intersubjective matrix, which both contains and gives

form to our mental lives through continuous interacting with each other. Stern

understands the therapeutic process as the regulation of the intersubjective field

between therapist and child in the service of development. Both Trevarthen (1980)

and Stern (2000, 2004) emphasize how the experience of mutuality arises from

subjective positions, implying therapeutic development as an expansion of both

intersubjectivity and subjectivity, as well as tolerance of separateness.

The following are definitions of concepts relating to the study, placed alphabetically:

Affects will be applied, in the study, as the main term in describing processes relating

to expressing and sharing affective information. Affect is understood as an

overarching concept to describe anything related to emotions or mood (Gross, 1998).

In the literature, affects and emotions are both applied to describe human experience

and processes such as emotion regulation. I will therefore use both terms according to

relevant literature and research. Daniel Stern emphasize that in describing subjective

experiences, he uses the word feelings, considering it to be the closest to personal,

subjective emotional experiences.

Affect attunement refers to an intersubjective process, characterized by a cross

modal matching of the child´s expression. The attention is thereby on the feelings

quality being shared. Misattunement is when the feeling intensity is either too strong

or too weak and does not match the child’s. If a child´s feeling is not attuned to over

time, the consequence is serious for the child´s inner world of feelings, often resulting

in withdrawal or loss of contact.

Affective scaffolding (Tronick, 1998, 2004) refers to how the therapist organizes the

affective regulating dialogue with the child to support expansion and development.

Dyadic expansion of consciousness model (Tronick, 2005) views therapist and child

as self-organising systems, which expands and reorganises through new relational

experiences. When mental balance in the child breaks down because of an interactive

error (for instance when the therapist misunderstands, mismatches or overhears), there

27

is an opportunity for dyadic expansion following an interactive repair. In this model,

the improvisational sloppy character of therapeutic dialogues guarantee episodes of

miscoordination, with the potential of developing interactive meaning into greater

complexity, from repeated experiences of restoring mutual coordination.

Forms of vitality is linked to dynamic subjective experiences and the understanding

of vitality affects as profoundly intersubjective and refers to a more precise

description of human capability to share mental worlds (Stern, 2010).

Imitation of the other´s action has a key role in establishing mutual attention and

discover similarities between self and others (Meltzoff & Moore, 1998). Imitation

takes place in relation to dynamic, rhythmical and temporal qualities in movements,

gestures, facial expressions and vocal tonality (Fernald, 1985).

Implicit relational knowing (Stern, 2004) is non-verbal, non-symbolic, procedural

and non-conscious processes, which develops parallel with explicit knowing

throughout life (Stern, 2004, p. 113).

Internalizing disorders in children, such as depressive and anxiety disorders, has

been less researched than other areas of psychopathology, such as overtly, disruptive

behaviour (Tandon, Cardeli & Luby, 2011) mainly due to these children being easier

to handle for the environment. Nonetheless, for children suffering with internalizing

disorders, such as anxiety and depression, and have limited ability to describe internal

feeling states the need for clinical research and help is imperative.

Intersubjective consciousness has been proposed by Stern, as a description of a form

of dyadic consciousness arising in the here-and-now from a mutually created intense

dyadic experience. It involves an overlap of subjective consciousness, partially

including the consciousness of the other and an awareness of sharing the same mental

landscape in the present.

Intersubjective field involves intersubjective motives directing and organizing

activity (Stern, 2004). Such motives are 1) A need to read the intentions and feelings

of another to orient in the intersubjective field (p.106). 2) A need to define, maintain

and re-establish self-identity and self-cohesion. The understanding is that self-

identity, continuity and meaning emerges from intersubjective experiences (ibid.)

Joint (mutual) attention is considered a basic intersubjective sharing and crucial for

the experience of togetherness and development of social skills.

Mentalization refers to the ability to interpret meaning from other´s behaviour by

evaluating their underlying mental states and intentions, and at the same time have the

capability to understand implications of one’s own affects and actions on others

(Fonagy & Target, 1996, 1997).


28

Microprocesses. Infant research, which has inspired the study, has contributed to

empirically based knowledge about the significance of microprocesses and about

forms of micro interplay, which are at the heart of the subjective experience of sharing

activity and meaning. Microprocesses direct focus to what is going on here-and -now

in the therapeutic interplay with the individual child, and to how this interplay can

attain developmental potential.

Modulation is also a musical concept and refers to an intersubjective process whereby

the child is helped to move from one emotional experience to another and is part of

the development of emotion regulation when the experience is internalized in the

child. Modulation may interweave and coincide with synchronization.

Musical parameters refer to aspects of musical sound, which can be varied and

described independent of each other and the traditional elements of music; such as

rhythm, melody, harmony, timbre and form. Such aspects are pitch, duration,

intensity, tempo, attack and vocal tonality etc. These aspects play an important role in

the present microanalytic study, where they are applied to describe dynamic

subjective experiences, such as dynamic forms of vitality.

Self-agency refers to the basic experience of being an agent capable of influencing

one’s own life through influencing the feelings and activity of others. It is considered

a key sense of self, embedded in the domain of core sense of self (Stern, 1985/2000)

and crucial for self- and self-with-others development as well as mentalization

(Midgley et al., 2017).

Synchronization means to adjust one´s activity to create and establish mutuality and

dialogue. It is considered a primary form of communication to establish

intersubjectivity (Trevarthen, 1979; Stern, 1985/2000).

Vitality affects (Stern, 2000) refers to the continuous, dynamic and changing flow

characterizing all mental life, as something more than categorial emotions as

described by Darwin. It is significant for the understanding of communicative

microprocesses in the study.

29

1.5. OVERALL STRUCTURE OF THE STUDY

The following figure shows an overview of the context for the present microanalytic

study, within a multicenter mixed method study. N here indicates the aimed for

number, not the resulting number of children.

Figure 1. Overview of microstudy

1.5.1. FIGURE 2. FLOWCHART OF THE MULTICENTER RESEARCH STUDY

The following flowchart describes how the PhD study is part of the multicenter study

as a separate qualitative part. Text in red indicates the specific elements and steps of

the present microanalytic study.

TIC

(TIC

((((TIC


30

31

1.5.2. THERAPY METHOD/TIME-LIMITED INTERSUBJECTIVE CHILD PSYCHOTHERAPY

The therapy method applied in the multicenter study is time-limited intersubjective

therapy (Svendsen & Johns, 2012; Johns & Svendsen, 2016), which is developed as a

method for children, from a psychodynamic approach (Proskauer, 1969, 1971;

Peterlin & Sloves, 1985; Sloves & Peterlin, 1986). It has later been developed as a

mentalization based method (Midgley et al., 2017) in addition to an intersubjective

method. The latter is applied in this study, integrating knowledge from infant research

(Haugvik & Johns, 2008; Hansen, 2012) and combining structure and flexibility

through three distinct criteria: 1) Establishing a clear time-frame, 2) parallel sessions

with parents and 3) a mutually agreed shared therapy focus (Haugvik & Johns, 2008;

Johns & Svendsen, 2016). The concept of time-limitation represents two aspects of

time (Johns, 2008): 1. An overarching time structure of the number of weekly sessions

aimed at therapeutic alliance and 2. Predictability and repetition aiming at a

restoration of the sense of continuity and integration of emotional experience in

children who have reduced sense of continuity and affect-integration (ibid.).

The focus comprises an understanding of the child´s developmental needs.

Formulating an understandable therapy focus is intended to facilitate recognition in

the child and parents of their own experiential world as significant in the therapy

process. Gaining the parents´ consent and commitment, as well as creating curiosity

about themselves and the child has priority. Within a musical frame, the focus can be

compared to one or more ‘leitmotifs’; a reminder of central themes to be elaborated

(Johns, 2008). The goal for parental work is increased mentalization capability

(Haugvik, 2013; Midgley et al., 2017). The therapy process with the child is a flexible,

mutually created process from what emerges in the dialogue and directed at self-

development. Taking the child´s perspective in the here and now is in the forefront.

Children have a shorter time horizon than adults, and their life form takes place to a

larger degree in the present (Lyons-Ruth, 2006). This implies an intersubjective

perspective directed at sharing attention, intention and affective states on a microlevel,

where the child´s history emerges implicitly and explicitly (Hansen, 1991a, 1991b,

2012). The therapist has an active role through the sessions in exploring the child´s

feelings, intentions and thoughts, as these are expressed implicitly and explicitly, and

from there creating new meaning. As part of the multicentre research study, from

which the data in this study originates, a handbook was written, describing theory and

principles of the therapy method, based on research so far (Johns & Svendsen, 2016).


32

1.5.3. SUMMARY OF HANDBOOK OF TIME-LIMITED INTERSUBJECTIVE CHILD THERAPY (TIC)

The following is a summary of the content of the Handbook of Intersubjective Child

Psychotherapy which was written as part of the PhD study and based on preliminary

findings in the multicenter project (Johns & Svendsen, 2016). The purpose of writing

a handbook of the therapy method was to give a thorough description of the

knowledge base and treatment principles which the therapy method builds on and give

examples to clarify. The acronym (TIB) is translated to TIC in English. We thought

that clear guidelines would serve as a helpful tool in the training of therapists. Also,

that it would clarify treatment procedures in clinical research using this therapy

33

method, as in the present study. The following is a short summary of the five chapters

of the handbook (a detailed table of contents in English can be found in Appendix*):

Chapter one is an account of the theoretical knowledge base underlying time-limited

intersubjective child psychotherapy (TIC). The theoretical foundation is described

within four areas:

1. Developmental psychology.

This section describes developmental psychopathology which

builds on an understanding of how children are developed from

birth, via the interaction with others. This is called a transactional

model of development which illustrates the significance of

reciprocity and interactional, contextual embeddedness for the

development of disorders (Sameroff, 2009).

2. The intersubjective perspective on developmental- and change processes.

This section describes the main conceptual understanding, together

with central concepts which can be used as therapeutic relational

tools and gateways to therapeutic change (Hansen, 2012). Each of

the concepts are described, with examples from child

psychotherapy. Such concepts are: Turn-taking, imitation and

mutual attention. Next, the role of affective communication in

development is described and discussed, including basic nonverbal

forms, such as communicative musicality, narratives, dyadic

regulation and expansion, implicit relational knowing, forms of

vitality and affect attunement. All conceptual understanding is

exemplified from child psychotherapies. The five different

intersubjective forms of relating/’being together’ which can be

found and created in psychotherapy are.

1. Implicit sense of mutuality through affect

synchronization and mutual regulation and

includes early imitation and turn-taking

(primary intersubjectivity).

2. Mutual focus of attention involving something

which the child or therapist can draw attention

to as a source for interaction (secondary

intersubjectivity).

3. Intersubjective sharing and feeling understood

through affect attunement and selective

attunement.


34

4. To express oneself though symbols, language

and shared meaning-making. Play is an

important part of this way of being together.

5. To attribute feelings, intentions and thoughts to

oneself and others (mentalizing). This process

implies a perspective on mental life which

creates possibilities for reflecting upon the

motives and intentions of oneself and others -

outside the here and now (tertiary

intersubjectivity of second order (Bråten, 2007).

It comprises the ability to integrate experience

and create self-biographical meaning.

Stern’s model of development of self domains is

presented after this, as a way of formulating

areas that a child needs to develop. The different

domains of self-development are also linked to

the formulation of therapy foci, which is

described later in the book.

3. Emotion regulation as a dyadic regulation system is described, with reference

to research.

4. Creative expressive art forms – play, music and drawing are presented with

examples from child psychotherapy.

In Chapter two the frame and structure of the therapy method is introduced, with a

detailed description of the three distinct elements of time-limitation, a shared therapy

focus’ and parallel work with parents. As mentioned before, the combination of

structure and flexibility is found to suit the work with children and parents. In the

following section on the role of metaphorically formulated therapy foci, with

examples of such formulations are provided. Examples very often emerge from the

work with individual children and from their individual way of expressing

nonverbally or verbally their inner world, inspiring various metaphors. Formulations

are organized in the handbook in the following way, here providing one example (The

book gives several examples):

▪ The therapy focus is directed towards development of self-regulation and

self-agency.

o We are going to be together and explore ways in which you can

become ‘just strong enough’. This is related to the child becoming

either ‘too strong’, implicating losing control or having to pretend

35

to be stronger than is the case and therefore not being able to express

authentic feelings of insecurity or ask for help.

▪ The therapy focus is directed toward emotional areas that the child does not

have contact with. The child needs help to direct attention to the inner world

to be able to express emotions and experience intersubjective sharing.

o We can be together here to help you to ‘sing all of your tones loud

and clear’. This focus was used in therapeutic work with a girl, who

showed very little emotions, especially anger and sadness, which

inferred with her daily life. The suggested focus was inspired by the

girls love for singing.

▪ The child needs help to experience coherence and continuity in self-

biography.

o Here we can try to get to know both the big and the little girl, to try

to find out what it is like to be seven years and having experienced

so much. The focus points to overwhelming and potentially

traumatic events, effecting development and that the child takes on

too much responsibility. The focus is a recognition of children’s

right to be children.

Parallel work with parents is described in detail, with the perspective on parent work

as an arena for developing mentalization. For such development to take place, the

parents’ feelings, expectations and needs must be understood and acknowledged.

Chapter 3 and 4 give a step by step description and overview of the whole therapeutic

process, with clinical examples to illustrate each of the steps. In chapter 3, the first

meeting with the family and the following three parallel meetings with the child and

parents, called clinical interviews, are described. These meetings are summarized with

all participants, in a joint meeting called the focus meeting, in which the suggested

therapy focus is discussed and agreed on. In chapter 4, overarching relational themes

of the three phases in the therapy process are described: 1) To create a helping

relationship. This formulation represents findings from a research project on what

therapists do in the first therapy sessions with children, to create a working alliance

(Svendsen, 2007). To present oneself as a helper, was considered a key factor of

alliance building, and Svendsen found two distinctive domains of helping maneuvers

across therapists with different theoretical orientations (ibid.). The first domain

comprises implicit maneuvers and the second comprises explicit maneuvers, which

are described in the handbook (p. 88). 2) Now we are working together describes the

second phase of therapy, and 3) To keep each other in mind is the name of the last

phase, referring to the developmental bearing underlying this therapy method. Each

phase includes descriptions of both child-directed and parent-directed work.


36

Chapter 5 describes the therapy processes with two children, in detail. The first

therapy process takes place during twelve therapy sessions. The second therapy

process is an example of a long-term therapy, with three sequences of twelve sessions,

being compared to ‘chapters’ within the child’s self-biography. Parallel work with

parents, schools and other significant persons and institutions in the child’s life are

described, according to the principles in the handbook of time-limited intersubjective

child psychotherapy.

1.6. SHORT SUMMARY OF THE ARTICLES OF THIS PHD

This PhD study is article-based, according to the structure for PhD studies at the

Aalborg University doctoral program. The two articles, which will be presented

under, aim at answering research questions, the first by addressing methodological

issues and the second by presenting and discussing findings from the microanalytical

study.

1.6.1. ARTICLE 1 (PUBLISHED)

Exploring musical dynamics in therapeutic interplay with children: A multi-

layered method of microanalysis

This article describes how a research procedure was developed, with the research aim

of exploring, describing and illuminating therapeutic exchanges with children at a

microlevel. The research task was approached from a musical perspective, inspired by

how infant research apply musical parameters, such as rhythm, tempo and vocal

tonality to describe relationship qualities. The background is psychotherapy research,

which validates the significance of relationship factors for change processes,

independent of any therapy method (Orlinsky, Rønnestad & Willutski, 2004). Relevant infant research is presented, as well as knowledge from music therapy,

indicating the significance of a musical foundation of affective communication. This

is in accordance with clinical experience from child psychotherapy and how the inner

worlds of children are expressed through dynamic, vocal, rhythmical and temporal

changes. Musical parameters were applied in the article as concrete descriptions of

the specificity of therapeutic intersubjective exchanges with children as these unfold.

Concepts which bridge an intersubjective and ‘musical’ understanding of

intersubjectivity, such as forms of vitality, are included. Data were taken from a

multicenter research study, with which the author collaborated and comprised six

37

children 9-13 with poor emotion regulation capability (see Figures 1 and 2 above).

The overall research aim of the multicenter study was to study changes in emotion

regulation in children with internalizing difficulties, receiving time-limited

intersubjective psychotherapy. This is a developmentally informed therapy method

applying intersubjective knowledge and adopted to the individual child.

Foreknowledge about emotion regulation and the therapy method is described in the

article.

The article goes on to describe the procedure which were followed for purposeful

sampling according to finding emotion regulation samples to include in the

development of the research method for microanalyses. The result was a multilayered

method for microanalysis, including three layers in the research procedure of selected

video samples: 1) A detailed description of moment-to-moment therapeutic

exchanges, organized in units across a time-line to integrate and make comparisons.

2) Description of musical parameters which emerged in the therapeutic interplay and

3) Psychological description which was made based on a constant comparison

between the three levels, applying concepts from a developmental intersubjective

perspective. Sequences of change in emotion regulation were identified during the

sample. Lastly dyadic themes from intersubjective theory were identified based on

interactive exchanges within and across units. During the constant comparison process

the concept of musical dynamics emerged as a synthesis of musical parameters and

forms of vitality. The article includes an example from therapy of how the method is

applied.

In the discussion it is argued that a multilayered approach to understanding therapeutic

change processes, such as changes in emotion regulation, has a potential for a

complementary understanding of implicit and explicit processes. Musical dynamics is

discussed as a useful concept, with the potential of clarifying micro interplay with the

child. During procedures of microanalysis, musical dynamics stood out as facilitators

of change. It is proposed that a focus on musical dynamics promote attention to signals

in the children´s expressions, indicating subjective intentions, feelings and therapeutic

needs. This again may promote the therapist´s responsivity and involvement in

therapeutic microprocesses, bearing importance for therapeutic development. In the

conclusion, a focus on musical dynamics, as part of a multilayered microanalytic

procedure, is seen as a useful concept for illuminating features of break-downs and

repairs of intersubjective sharing, which is at the heart of an intersubjective

developmental perspective on therapeutic change.


38

1.6.2. ARTICLE 2 (SUBMITTED)

A study of musical dynamics in therapeutic interplay with children. ‘The

important thing was to be understood through tone of voice and movements’

Samples of emotion regulation from the course of time-limited intersubjective child

psychotherapy with six children were analyzed within and across samples. Two

samples, from an early and a late session with each child, were analysed according to

the multi-layered method of video microanalysis, including a musical frame as well

as a psychological. The musical frame is a registration of vocal, rhythmical, dynamic

and temporal changes as concrete descriptions of the specificity of therapeutic

exchanges, as these unfold. The research questions guiding the microanalysis

presented in the article was 1) How can a description of musical dynamics, within a

multilayered frame, illuminate intersubjective microprocesses, and 2) How does a

description of musical dynamics, applied together with psychological knowledge,

clarify therapeutic interplay and basic developmental processes such as emotion

regulation in child psychotherapy.

Data came, as described in Figure 2 above, from six children taking part in a mixed

method multicenter research project on changes in emotion regulation. All therapy

sessions were videotaped, which was the total data material for the present qualitative

micro study. Emotion regulation was measured in the multicentre research project

with quantitative measures, before and after therapy, including symptom scales,

psychobiological measurements and the Affect Consciousness Interview. The goal of

the present microanalytic study described in article 2 was to explore how an analysis

of musical dynamics can elucidate therapeutic interplay facilitating self-development.

The multi-layered microanalysis of data resulted in identification of eight overarching

patterns of therapeutic interplay involved in emotion regulation samples: Four

described musical dynamics in the therapists´ activity: (1a) Therapists regulating the

child´s lack of coherent rhythm by slowing down tempo and providing more space can

promote intersubjective sharing and continuity; (1b)) Vocal tonality and vocal

contour of therapists can serve as invitation and support for the child to share a wider

feeling range; (1c) Therapists´ mismatches can be associated with therapist´s

eagerness to explore difficult feelings; (1d) Therapists adjusting rhythm and tempo

towards establishing, keeping and using a ground rhythm can enhance intersubjective

sharing. Two patterns described musical dynamics in the child´s activity: (2a) High

correspondence between tempo and dynamics can foster an impression of

intentionality; (2b) Distinct changes in the child´s musical dynamics can be associated

with dyadic synchronizing opportunities of significant feelings. Two patterns

described dyadic synchronization patterns: (3a) Rhythmical flow in dyadic

synchronization can render the child clearer and more expressive and enhance self-

39

agency; (3b) A musical dynamics description can contribute to clarify processes of

interactive errors and repairs. Examples from microanalysis of samples were chosen

to illustrate each pattern and represented a condensation of the raw material, which

had been integrated into a narrative based on the multilayered microanalysis.

The affect consciousness interview, which has been adopted for children was

described. Measurements from pre- and post-tests with the affect consciousness

interviews with all six children were presented in detail. The measurements indicate

increased affect integration and development of emotion regulation capability towards

age adequate status for the age group. Findings suggest that adjustments or

sustainment in rhythm, tempo, vocal tonality, intensity and pauses, play a significant

part in microlevel change processes, and to the multilayered understanding of these.

Specifically, a musical dynamics description brought out patterns in subjective

contributions in the interplay. Also, increase in vitality and affect integration indicate

improvement in self-regulation capacity.

Implications of findings in relation to research questions are discussed and elaborated.

From an intersubjective perspective it is questioned whether a musical dynamics

description, in addition to having a potential for illuminating the child´s expressions,

also brings attention to therapeutic qualities as perceived by the child. How a child is

met and understood psychologically bears significance on alliance building, trust and

involvement in the therapeutic process. This is experienced directly by the individual

child, not primarily because of good therapeutic techniques, but because of the

therapist´s emotional availability and developmental empathy. It is suggested that a

musical dynamics perspective helps the therapist in bringing awareness to her/his way

of attuning and synchronizing to the individual child. More empirical research on

microprocesses in therapeutic interplay with children is warranted, to clarify

phenomena influencing therapeutic development.


40

CHAPTER 2. LITERATURE REVIEW

AND THEORETICAL BACKGROUND

2.1. AN OVERVIEW OF EMPIRICAL STUDIES IN CHILD PSYCHOTHERAPY

I will firstly give an overview of some data on psychological disorders in children,

and on the main internalizing disorders of depression and anxiety, as a background

for empirical studies. Data from studies in Norway (Heiervang et al., 2007; Wichstrøm

et al. 2012) shows that 7 percent of Norwegian children suffer from symptoms of a

psychological disorder. 5 percent of children 0-17 receive treatment in outpatient

clinics (ibid.). Depression occurs in all age groups, with an increase from 1,6 percent

before adolescence to 14.3 percent for adolescents. For younger children numbers

indicate that depression is not discovered or diagnosed due to children´s lack of verbal

skills for emotions. For anxiety, the percentage is up to 3.2 for preadolescents,

increasing to 6.9 percent for adolescents (Wichstrøm et al., 2012). As mentioned

earlier, internalizing disorders have lagged behind compared to research on other

psychological disorders, supposedly because these are children with less presenting

challenges for their surroundings (Tandon et al., 2009). Children with internalizing

problems usually appear withdrawn, shy and fearful. None the less, depression and

anxiety have a profound impact on the lives of children, with experiences of

helplessness/hopelessness, intense fear, irritability, worry and uneasiness,

representing emotional, social and cognitive challenges in their everyday life.

There are today many evidence-based treatments for children and families (Kazdin,

2004; Midgley et al., 2017). Mostly these treatments have been developed for specific

diagnostic populations, and as Midgley points out (2017, p. 4), it is unrealistic for

child therapists to be trained in all. An additional problem is that many children either

drop out of treatment or are not able to profit from available treatments (Shirk, 2002).

There is also research which shows that for many children and parents a lack of

emotion regulation capability makes them unable to follow treatment procedures

(Scott & Dadds, 2009).

A search in the Psycinfo Database [250718], using the keywords psychodynamic

psychotherapy + children + intersubjectivity resulted in identifying a very limited

number of studies. Especially empirical studies are rare. The most important studies

are described in the following. In referring empirical studies in child psychotherapy,

I am limiting myself to studies with children and adolescents, bearing relevance for

the present study. I will therefore not include empirical studies on CBT. Most of the

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described empirical studies are therefore within psychodynamic psychotherapy. Since

this term covers many different approaches, I will quote the definition of Kegerreis

and Midgley (2014), which comes close to the definition of intersubjective child

psychotherapy: “…the central idea…. that behaviour, emotions and responses, have

an inherent logic and meaning – a way in which the child’s problems, despite apparent

unhelpfulness, make some kind of emotional sense. Their roots lie in the internal

world of the child that has been built up from his/her earliest experiences and

relationships” (p. 38). During the last decades, psychodynamic psychotherapy has

developed and integrated ideas from several areas of research, such as infant research,

attachment theory and neuropsychology (Lanyado & Horne, 2009; Kegerreis &

Midgley, 2014). This has led to an increasing number on short-term/time-limited

approaches which integrate developmental theory and research, such as

mentalization-based time-limited treatment for children (Midgley et al., 2017) and

intersubjective time-limited psychotherapy for children which is applied in the present

study (Haugvik & Johns, 2008). As of now, there are few empirical studies on these

approaches. Considering knowledge so far from empirical studies on child

psychotherapy, this supports findings from adult psychotherapy that therapy has an

effect (Kazdin, 2002; Shirk & Karver, 2003; Weisz & Kazdin, 2017) and that

relational qualities are related to outcome (Shirk & Saiz, 1992; Shirk & Karver). The

therapeutic relationship has been regarded as a common factor within adult

psychotherapy, across different interventions and patient groups (Orlinsky, Rønnestad

& Willutzki, 2004). A meta-analytic review (Shirk & Karver, 2003) indicated that the

therapeutic relationship impact outcome across different types of child and adolescent

therapies. Their conclusion is to view relationship qualities as a central and effective

factor also in child psychotherapy. Shirk and Russel (1996) have for long emphasized

the importance of being able to gain “a more precise understanding of the change

process embedded in therapeutic relationships” (p. 184).

In 2017 Midgley et al., made an updated narrative review of a former critical review

(Midgley & Kennedy, 2011) of the evidence base for psychodynamic psychotherapy

for children and adolescents. It is worth mentioning that findings in the first review

suggested that child psychotherapy without parallel work with parents might have

negative effect on family functioning (Midgley et al. 2017: 309). Also, that children

with internalizing disorders responded better than children with externalizing

disorders (ibid). Of critical remarks concerning the quality of the available data base,

the authors point out how heterogeneous clinical populations, large variability in

interventions and methodological limitations made it difficult to make conclusions.

They also point out that studies made very few references to other studies, or built on

previous research, limiting the cumulation of knowledge from research. Before 2011,

almost no treatment procedures have been manualized within individual

psychodynamic psychotherapy, which have added uncertainty regarding the


42

procedures of interventions and potential similarities potent for comparison. However,

since then several treatment manuals have been published, making the treatment

design more transparent and eligible for evaluation. In the 2017 review (Midgley et

al., 2017), the authors follow the same methods as in the earlier review: Inclusion

criteria are children and adolescents between 3-18 years, short and long-term

treatments specified as psychodynamic and with a focus on evaluation treatment

outcomes as well as met criteria for inclusion. RCT studies were regarded as providing

stringer evidence of effectiveness. A total of 23 studies met inclusion criteria, 5 being

RCT studies, and are described in relation to groups of psychiatric diagnoses. I will

shortly describe findings concerning children with internalizing disorders: The largest

outcome study on psychodynamic psychotherapy (Goodyer et al., 2017), is an RCT

study comparing treatment with a psychodynamic short-term approach (STPP) and

CBT with a brief psychosocial intervention. Results showed equal effectiveness and

maintenance in reduction of depressive symptoms one year after treatment ended.

Improvements in the STPP group included a larger percentage of reduced symptoms

at the long-term follow up. Also, there was a relapse of 4 percent, compared to 16.5

in the CBT group, indicating long-term effectiveness. The review of studies on

anxiety disorders show few studies. In one, ten participants from 8-16 received a

manualized weekly treatment of 12 sessions. After treatment they no longer met

criteria for an anxiety disorder with improvements across all outcome measures and

in general functioning. Improvements were still present after six months. However,

the study showed a limitation in methodological requirements, such as small sample

sizes and lack of control group, which call for more research.

A meta-analysis of short term psychodynamic psychotherapy (STPP) models for

children was carried out by Abbas et al. (2013). They claim this to be the first

evaluation of treatment effectiveness, although such approaches are widely used for a

range of psychiatric disorders in children. Their findings indicate that STPP can have

positive outcomes across a wide range of psychiatric disorders, and that there is a

tendency that treatment improvements increase during follow-ups. However, more

systematic studies are needed. Out of the treatment approaches which build on

knowledge from attachment theory and empirical studies on mentalization,

mentalization-based treatment for children (MBT-C) is currently the most widely

used. A thorough and comprehensive treatment guide was written in 2017 (Midgley,

Ensink, Lindquist, Malmberg & Muller). The approach aims at promoting the

development of mentalization and resilience in children and parents (ibid). Peter

Fonagy puts words on the status of treatment approaches for children when he states

that ‘It is somewhat paradoxical that the maturity of an approach should have as its

marker the extension to the world of children’ (ibid, p. vii).

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The Erica Process and Oucome Study (EPOS) (Odhammar et al., 2011) was an

observation study without a control group. The research aim was to investigate

whether global functioning improved after treatment with short-term psychodynamic

psychotherapy. Sample size was 33 children with AD/HD or behaviour problems

between 4-10 years and their parents. When measured after treatment with CGAS

(Children´s Global Assessment Scale) and HCAM (Hamstead Child Adotion Scale)

effect size was 1.80 and 1.98. The study supports that parallel treatment with children

and parents can have positive effects, but the authors conclude that more research are

needed to identify which factors contribute to the change (Odhammar et al., 2011).

Empirical studies researching the outcome of time-limited intersubjective

psychotherapy with children are to my knowledge limited to the one conducted at the

Akershus university hospital outpatient child and adolescent clinic, Furuset with 9

children experiencing difficult family situations (Haugvik & Johns, 2006, 2008;

Johns, 2008; Haugvik, 2013; Haugvik & Mossige, 2017). In this study a wide range

of symptom scales were applied to measure outcomes after therapy and at a three-

months follow-up, in addition to parent interviews and video analysis. Results from

symptom scales showed an effect-size of 0.66 right after therapy and 0.74 three

months after therapy ended, which were in accordance with improvements reported

by parents. The second known study is the present collaborative research study

between this outpatient clinic and the Norweg

musical dynamics in time-limited intersubjective child … · prof. leslie bunt prof. katharina...

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